Cost Pressures – The economic situation for pharmacies is complicated by several forces putting pressure on them:

The growth of the Pharmacy Benefit Management (PBM) company has increased the concentration of insured lives within a few Fortune 100 companies forcing the pharmacies to accept lower reimbursement rates;

There are now more than 55,000 retail pharmacies in the US and an overcapacity of mail order pharmacies which is more than can be profitably supported;

The largest companies such as Walgreens are rapidly leveraging innovative technologies to allow them to fill drugs at a much lower cost while others are clinging to a high touch, convenience model that is not sustainable; and

A shortage of thousands of pharmacists in the US has driven starting salaries for pharmacists above $100,000 in some markets.

Growth – The cost pressures facing pharmacies are mitigated by two things – inflation and utilization. Both continue to go up year over year and have dulled the effect of economic pressure. According to Express Scripts 2004 Drug Trend Report, Per Member Per Year (PMPY) utilization is 13.1 prescriptions for insured patients. Assuming a 6% annual growth in prescription utilization, that means that the average insured consumer would use 18.6 prescriptions PMPY by 2010.

Pharmacist Staffing – A recent article estimated that the current pharmacist shortage in the US of 4,000 to 8,000 open positions will increase to 157,000 by 2020. This staffing crunch combined with the payor’s move to consumer driven healthcare where the patient has greater responsibility for their healthcare dollars will put incredible stress on the system. Just as patients need the trusted pharmacist to play counselor or coach, the workload will have increased to the point where they do not have the time to spend with them. In 2005, these issues led Walgreens pharmacists to briefly strike noting the risk to patient safety.

New Models – An increasing number of employers are building on-site pharmacies, and several companies are piloting “vending machine” type solutions for pick-up of dispensed medications. In late 2005, the Department of Defense issued an RFI to explore a telepharmacy solution to replace their Military Treatment Facilities (MTFs) . Some states such as North Dakota are piloting a telepharmacy solution which is a model allowed in several states where a pharmacy technician can dispense while being monitored remotely by a pharmacist.

Patient Satisfaction – Although studies show that pharmacy patients are generally satisfied, 56% of household consumers report that they use more than one pharmacy to fill prescriptions according to the WilsonRx Report 2005. And, according to NACDS, 68% of people choose a pharmacy based on location.

Loyalty – Even though location is a huge influencer, a Morgan Stanley report showed that the willingness to switch to mail was highest at big chains – Walgreens (44%), Wal-Mart (41%), and CVS (35%). Given the concentration of marketshare in these stores and their growth forecasts, it seems logical that the marketshare could be re-distributed to locations that are already visited like grocery stores. According to the Food Marketing Institute (FMI) shoppers make and average of 2.2 visits to the grocery store each week.

Consumer Driven Healthcare (CDHC) – CDHC is used to refer to a lot of different scenarios in which the burden for managing cost is pushed to the patient. This includes high deductible plans, Health Reimbursement Arrangements (HRAs), Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs). One of the biggest issues is that this is similar to the movement to 401K plans, but in healthcare, there is no decision support infrastructure. Initial estimates are that 40% of employers will offer this type of plan design over the next few years. This will put pressure on the pharmacist to act as this decision support resource.

Aging of the Population – With the ongoing aging of the population and forecasted growth in people age 65+, this growth in prescription drug use will continue. Based on the Medical</a Expenditure Survey from 2002, the differences in utilization of prescriptions increases dramatically as people age. For example, people 35 to 44 use 7 prescriptions per year while those 45 to 54 use 12 prescriptions per year and those 65 to 74 use 24 prescriptions per year.